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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 10/14/2025
Date Signed: 10/14/2025 01:46:11 PM

Document Has Been Signed on 10/14/2025 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR/
DIRECTOR:		RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 175CENSUS: 92DATE:
10/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Ryan Nakao TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/14/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management to address the deficiencies observed / learned during complaint investigation # 27-AS-20250131102041. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Ryan Nakao and a brief interview followed.

Staff interviewed (S1, S3 and S8) told this LPA that they had observed changes in resident (R1) but there was no written documentation noting these changes.

Observation of the Resident 87466
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This LPA learned during the course of the investigation that staff (S13) were not conducting 2 hour checks. (initials were on the checklist for NOC care staff on the 18th (S13), but resident would not have been on the floor in their daytime clothes and soaked if the checks had been done). The NOC shift caregiver checked off they did 2 hour checks on the 19th and R1 wasn't even in the building - they were at the hospital.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
VISIT DATE: 10/14/2025
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CCR 87411 Personnel
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.  In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports.  Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.  The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

LPA asked the Executive Director (ED) for any internal witness statements that were taken and/or submitted to the ED regarding R1.  The ED stated that they did not have any.  LPA received a copy of a statement that documented observations from that morning when R1 was found. 

CCR 87207  False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

While investigating this complaint this LPA was made aware that on Sunday, 9/21/25, the Executive Director, who has not had medication technician training, was administering medications in memory care. 

CCR 87465(h)(6), Incidental and Medical and Dental Care
Staff responsible for assisting residents with self-administration of medications shall receive training as specified in Section 1569 69 of the Health and Safety Code before they assist residents with medications.

According to the California Code of Regulations, Title 22, these deficiencies were cited on the following
LIC 809D pages. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Ryan Nakao.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/14/2025 01:46 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/14/2025 at 09:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
87466

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Observation of the Resident 87466
The licensee shall ensure... regularly observed for changes in physical, mental, emotional and social functioning... changes are documented...
The Licensee did not ensure the above requirement was met as evidenced by:
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ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.
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Based on document review, staff interviewed (S1, S3 and S8) told this LPA that they had observed changes in resident (R1) but there was no written documentation noting these changes. This posed an potential threat to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2025 01:46 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/14/2025 at 10:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87465(h)(6)

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Incidental and Medical and Dental Care CCR 87465(h)(6) Staff responsible for assisting residents with self admin. of meds shall receive training as specified in...before they assist residents with medications. The Licensee did not me the above requirement as evidenced by:



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ED to start Medication Technician trainining tomorrow on 10/15/25 and will send a copy of their progress sheet by the close of business tomorrow 10/15/25 to: CCLASCPSacramerntoRO@dss.ca.gov.
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Based on a review of the EMAR for Sunday 9/21/25, the Executive Director, who has not had medication technician training, was administering medications in memory care. This posed an immediate risk to the health, safety and personal rights or residents in care.
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Type A
10/15/2025
Section Cited
CCR87411(a)

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Personnel 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

The Licensee did not ensure the above requirement was met as evidenced by:
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Director of Care will review cross-over sign-off sheets daily to ensure all tasks have been completed. ED and DC will create a cross-over sign-off sheet that will be submitted by the close of business tomorrow to CCLASCPSacramerntoRO@dss.ca.gov.
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Based on a document review staff (S13) did not conduct 2 hr checks on R1, their initials were on the checklist for NOC shift on 1/18/25, but R1 would not have been on the floor in their daytime clothes and soaked in urine if the checks had been done. This posed an immediate threat to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/14/2025 01:46 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/14/2025 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87207

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False Claims 87207
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
The Licensee did not ensure that the above requirement was met as evidenced by:
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ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.
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LPA received a copy of a statement that documented observations from that morning when R1 was found. This posed an potential threat to the health, safety and personal rights or residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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